YOUR CART

Special thanks to Alpine's Lymphedema Specialist, Antara Quiñones, DPT, for submitting this article for publication.

If you have had breast cancer treatment in the form of radiation, lumpectomy, or mastectomy, you are at increased risk of developing arm lymphedema.​Lymphedema is a failure of the lymphatic system to move lymph fluid out of the extremity. If left unchecked it can lead to skin changes, infection, and decreased function. The best results to avoid the development of lymphedema involve early intervention.

Here are some important items to know when it comes to post-cancer treatment:

Protect your arm from bug bites, sunburn, scrapes and scratches, and needles. Because your lymphatic system is also a part of your immune system, anything that taxes this can set off a swelling event.

We’d like to announce the Oncology Rehab Program at Alpine Physical Therapy. Our team, which includes Josie Sweeney, DPT, Antara Quinones DPT, CLT-LANA, and Jessica Kehoe DPT, want to bring to everyone’s attention that October is National Breast Cancer Awareness month. We will surely all see lots of pink stuff this month in sports and in the news honoring this month, but we really want to remind everyone that the reason for all this media is to encourage early detection.

Statistics show that nearly 1 in 8 women will be diagnosed with breast cancer in her lifetime. Early detection is the BEST way to beat this disease, and both the 5 year and long term survival rates drastically improve with early detection.

We encourage all women to talk about early detection with their friends and family. If you are a woman aged 40-49 talk to your doctor about when and how often to begin getting mammograms. If you have had a close family member with breast or ovarian cancer you are at a slightly greater risk, so no matter your age, be sure to talk to your doctor about your options for early detection. Join us in vowing to start, or get back to, your early detection plan.

Antara Quinones, doctor of physical therapy, of Alpine Physical Therapy earned her certification with the Lymphedema Association of North America as a certified lymphedema therapist in August 2015.​By completing the 135 hours of coursework and her national board exam, she is qualified to treat a host of patients with edema issues, including those affected by cancer treatment, venous system failure, or surgery. Contact Antara at Alpine’s North clinic at 541-2606.

Special thanks to star physical therapist Antara Quiñones of Alpine Physical Therapy for providing this write up on a recent article from the Journal of American Academy of Orthopedic Surgery.​*************

Toes are like teeth- you take them for granted until they hurt and then you realize how much you rely on them and are amazed at how much pain they can cause. Toe instability resulting in a rigid deformity is a common foot problem. A recent review article speaks to new knowledge of toe instability and a surgical technique that should be utilized—specifically, repairing the plantar plate.

In a healthy foot the tiny muscles of the feet and toes along with ligaments on the sides of your toe joints (collateral ligaments) and a thick piece of fibrous tissue on the pad of your feet and toes, called the plantar plate, help to resist the forces your toes undergo during walking and running. The second toe is most vulnerable to hyperextension because there is no muscle responsible for resisting your second toe moving towards your big toe. Authors of this review found that the plantar plate is primarily responsible for the stability at the 2nd toe joint. If this plantar plate is torn, due to abuse or trauma, and not repaired the toe instability becomes worse and typically results in a crossed toe.

Toe deformities go by various names depending on the direction the toe goes, but generally speaking a bent toe is called “hammer toe” which can turn into a toe stuck under or over the adjacent toe. Any deviation from a straight toe is an indication of joint instability and should be addressed to prevent future pain and walking difficulty.

Hammer toe is caused by outside pressure (like high heels), inflamed joints, and autoimmune diseases. Predisposing factors include genetics, a longer second toe, flat feet, and an already poorly aligned big toe. Curled toes, or hammer toes, most often happen to women older than 50 years old whose feet have been pressed into high heeled shoes with narrow toe boxes. Men and younger people can also develop hammer toe, however it is more rare. Often, these deformities are ignored until they become “fixed” or the bones have fused into place. Fused toes are problematic because as we push off with our back foot while walking the toes must bend and tolerate 40% of our body weight.

Symptoms of toe instability are pain on the bottom of your toe where it meets your foot, toe swelling and numbness, a feeling of “walking on marbles,” and a gradual change in the direction of your toe towards encroaching on its neighbor. It may be uncomfortable to walk barefoot or feel better to walk on the outsides of your feet. Imaging, such as x-rays or MRI, can diagnose hammer toe. However two simple tests combined show good diagnosis results: a “drawer test” to test the mobility of the joint, and trying to pull a piece of paper out from under the toe in standing.

Treatment of hammer toe depends on the extent of the instability of the toe joints. Often, people do not seek treatment until the toe has completely crossed under or over and has become rigid. Conservative treatment is moderately effective for early joint instability and includes shoe modification (lower high heels, wider toe box, more cushion), pads placed in the shoes or rocker bottom shoes to redirect the forces across the foot during walking, or steroid injections at the joint (keeping in mind that any steroid relieves pain but does disturb the already fraying tissues). Keeping your foot, ankle, and calf muscles strong can also help, as well as checking in with a physical therapist to help correct any faulty movement patterns further up the chain.

Surgery is a common option, especially for more advanced stages of hammer toe. Two main approaches are used–one accessing the area from the sole of the foot and the other from the top of the foot. Surgeons trim any unhealthy tissues and suture any obvious tears in the plantar plate and collateral ligaments.

In the past the collateral ligaments have been the primary tissue repaired. However, authors found better outcomes with surgery prioritizing plantar plate repair along with collateral ligament repair. They found that this helped significantly with lasting deformity correction and improvement in pain and a person’s ability to function.

Jesse Doty, M.D. Metatarsophalangeal Joint Instability of the Lesser Toes and Plantar Plate Deficiency. In Journal of American Academy of Orthopedic Surgery. April 2014. Vol. 22., No 4. Pp235-245.​For more information, visit this topic module on our clinic website by clicking here.

Special thanks to star physical therapist Antara Quiñones of Alpine Physical Therapy for providing this write up on a recent article from the Journal of American Academy of Orthopedic Surgery.​****************

Osteonecrosis of the femoral head most frequently affects 30 to 50 year olds, with 20,000-30,000 new cases diagnosed annually. Although the actual pathology behind femoral osteonecrosis is not yet understood, the disease typically follows a progression to eventual femoral collapse, which results in the need for a total hip replacement.

Osteonecrosis literally translates to bone death. There are several reasons why this can occur. Ischemia, or lack of blood flow, is one. This can happen from trauma, (like a hip dislocation or fracture), a blood clot blocking blood flow, or high blood pressure at the level of the bone tissue from excessive alcohol or corticosteroid use. Some genetic blood clot formation mutations have also been linked to femoral osteonecrosis. Disruption to the bone cells themselves by irradiation, chemotherapy, or the presence of excessive free radicals, also causes osteonecrosis. Primary risk factors include corticosteroid use, alcoholism, trauma, and coagulation disorders. They have found, however that a risk factor alone does not determine the onset of osteonecrosis, but that there must also be a genetic factor present.

The earlier the disease is diagnosed, the better the outcome. The most frequent symptom is deep groin pain that can radiate to the buttock or knee on the same side. The gold standard for femoral osteonecrosis detection is an MRI, which can give insight into the amount of bone death present, its location, and the amount of swelling in the bone. All of this information can help physicians treat the problem and predict whether or not the femoral head will “collapse.” which then means a need for a total hip replacement.

Nonsurgical treatment of femoral osteonecrosis is limited to smaller, symptom free lesions for a period of no weight bearing to see if symptoms do occur. Little evidence exists backing shockwaves and electromagnetic field treatment. Pharmacologic agents are also not strongly backed in the literature for prevention and treatment of femoral osteonecrosis.

Surgical treatment is the primary treatment option for femoral head osteonecrosis and consists of femoral head preserving procedures or total hip replacement. The type of femoral head preserving procedure is subject to debate and dependent on the extent and location of the bone death. Femoral head sparing procedures are also indicated for the younger patient.

Special thanks to star physical therapist Antara Quiñones of Alpine Physical Therapy for providing this write up on a recent article from the Journal of American Academy of Orthopedic Surgery.

*************​Every 5 years or so the American Academy of Orthopedic Surgeons (AAOS), along with a cohort of other professions (like physicians and physical therapists) publish a guideline to treat certain conditions based on the latest and greatest evidence. These guidelines offer a quick look into what’s proven to work, what does not work, and what still needs to be further investigated. Below are the items that the AAOS recommends for the most up to date treatment of knee arthritis.

People with knee arthritis should:1. Routinely take part in a strengthening program, neuromuscular education (or using techniques to restore balance, improve coordination and fine tune awareness of where your leg is in space), perform low-impact aerobic exercises, and keep physically fit to national standards in regards to heart health and body weight.

2. Maintain a body mass index (BMI) of less than 25.

3. Use nonsteroidal anti-inflammatory drugs (oral or topical) or tramadol to help with symptom management.

The following are NOT recommended for treatment of knee arthritis:1. Acupuncture

2.Lateral wedge insoles are not supported in the literature. This being said, however the recommendation is moderate and patient preference should be kept in mind.

3. The use of glucosamine and chondroitin.

4. The injection of hyaluronic acid into the knee joint.

5. Performing an arthroscopy with lavage and/or debridement in which the fluid of the knee joint is removed, the joint is washed, and any loose bodies or debris are removed.

6. The use of needle lavage where saline is injected into the joint and then removed in attempts to wash the joint and remove inflammatory factors and debris.

7. The use of free-floating (not cemented or screwed into place) interpositional devices in the inner knee compartment to alleviate pain and mimic meniscus function. (This was a general consensus recommendation due to the lack of research available for these devices.)

​Evidence is inconclusive for the following due to either lack of available evidence or inconsistencies in the studies that have occurred. Practitioners should be on the lookout for future evidence, but in the meantime decisions regarding their use should be influenced by their clinical judgment and patient preference.1. The use of physical agents, such as electrical stimulation and ultrasound.

2. Manual therapy.

3. Valgus knee brace (to unload the inner knee compartment).

4. The use of acetaminophen, opioids, or pain patches.

5. The use of injections into the knee joint of corticosteroid.

6. The use of growth factor injections and/or platelet rich plasma.

7. A valgus-producing proximal tibial osteotomy, or bone shaving that changes the direction of forces across the knee joint to relieve pressure at the inner knee.

As the evidence changes and our knowledge evolves, it is good to keep the AAOA standards in mind and to be on the look out for future recommendations.​David S. Jevsevar, M.D., MBA. Treatment of Osteoarthritis of the Knee: Evidence-Based Guideline, 2nd Edition. Journal of American Academy of Orthopedic Surgery. September 2013. Vol 21, No 9. Pp 571-576.For more information, visit our topic module on Knee Osteoarthritis by clicking here.

Special thanks to star physical therapist Antara Quiñones for providing this write up on a recent article from the Journal of American Academy of Orthopedic Surgery.

**************​Cadaver Cartilage Grafts Prove Promising for Large Cartilage Tears of the Knee

A recent review of the most up-to-date research found that large cartilage tears at the knee joint are best repaired with donations from cadavers. The review found that a technique called “Osteochondral Allograft Transplantation,” or OCA, is versatile in terms of what kinds of repairs it can help and has the best long-term effects when compared to alternative surgical options.

Chondral is a fancy word for cartilage. Cartilage is a protective layer of rubbery tissue that covers the ends of bones to prevent rubbing. There are two important layers of cartilage in the knee- one layer of articular cartilage that covers the end of each leg bone and your knee meniscus, which resemble rubbery washers that sit on top of the articular cartilage. Both of these can be damaged from trauma (like a side blow to the knee or excessive twisting forces) or they can degrade over time from normal wear and tear. Sometimes, due to abnormal forces across the knee joint or excessive use with improper form these pieces of tissue rub and tear earlier in life. This often happens to athletes who perform the same repetitive movements again and again or in athletes with high impact activities. In addition, if there are any muscle imbalances the knee joint moves at the less than optimal angle speeding up the wear and tear on the cartilage. This breakdown in the cartilage causes swelling at the knee, pain, and interferes with a person’s ability to perform their sport or typical functional tasks of life.

Cartilage does not have a good blood supply which means that it does not heal well. What’s more, it has no nerve endings so you do not really realize there is a problem until damage is done. Chondral degradation is graded on a scale from one to five, with five being the worst. Repair options hinge on the size and location of the tear as well as the goals of the patient.

Smaller lesions (<2 cm^2) are often repaired by clipping out the frayed pieces of cartilage (debridement), taking a piece of cartilage from another part of the knee and placing over the tear (osteochondral autograft transplantation), or by poking tiny holes in the bone below the cartilage so the blood clots formed will provide some healing and regrowth of fibrocartilage (microfracture). These techniques, however, are less effective for larger tears (>2cm^2 to <10 cm^2) or deep tears. Bigger tears are treated by either OCA or by an autologous chondrocyte implantation (ACI). An ACI procedure involves harvesting the cartilage cells and growing them outside the body and then planting them in the effected area. It is worth noting, however, that an OCA is the only back up procedure for a failed ACI. Authors of this review found that an OCA is less invasive (only one procedure), is more versatile, and has better long-term outcomes than an ACI.

The OCA procedure has become refined with time. The cartilage donation must be collected within 24 hours of the person passing away and is taken from people with healthy knees. The tissue is screened for a host of diseases. This process takes anywhere from 14 to 28 days, during which the cartilage is kept at body temperature, its ideal environment. The cartilage is then selected based on a size and location match, as there is a very minimal risk of tissue rejection since there is little to no immune response in cartilage. If the tear is deep and a bone graft is also required then the risk of rejection is only slightly higher.

An OCA procedure includes several different techniques depending on the type of tear. The most common technique is called a plug, where the chunk of torn cartilage, and perhaps bone, is removed and the new piece of cartilage is fitted perfectly in its place with as tight of a fit as possible. If the fit is not completely snug the surgeon can fasten it in using dissolvable materials or tiny hardware that will not disturb the knee function.

Rehabilitation after the surgery is broken into three phases. The first phase is a period of rest to allow the tissue to heal, with the amount of use of the leg depending on the type of repair. Typically phase one lasts 6 weeks. Phase two is from week six to twelve and involves return to daily activities, strengthening, and full motion of the knee. Phase three is from three months on and involves full return to sport with the guidance of a physical therapist. From six months up to one year after surgery repetitive high impact activities should be avoided.

Long-term outcomes for OCA procedures are promising with the greatest percentage of success in a younger, active population with traumatic onset of cartilage damage less than one year prior to surgery. That being said, however, the numbers are also promising for the non-traumatic middle-aged population with tears greater than 2cm. The authors suggest that an OCA become the standard practice for larger tears of these populations.

Seth L. Sherman, MD, et al. Fresh Osteochondral Allograft Transplantation for the Knee: Current Concepts. In Journal of American Academy of Orthopedic Surgery. February, 2014. Vol 22. No. 2. Pp. 121-133.​For more information on this topic, click here for an informative article that is on our website.

Special thanks for this article to Alpine super star, Antara Quinones, DPT.

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IASTM is short for Instrument Assisted Soft Tissue Mobilization and just might be the answer if you have been dealing with nagging, recurrent muscle or “soft tissue restrictions”. Ideally layers of muscle and fascia glide over one another as move through a range or contract muscle tissue.

Runner’s often end up with injuries that restrict that normal tissue mobility. This lack of mobility often causes pain and inability to run with proper form. Common examples include iliotibial band syndrome (ITB), plantar fasciitis, achilles tendinitis, chronic tight calf muscles. and hamstring strains.

IASTM is a technique physical therapists use to break up the adhesions between the tissue layers and bring blood flow to the area. The treatment is often intense at the time but is quick and highly effective if followed with good stretching and correction of faulty movement patterns.

Want to try it out? Alpine’s Physical Therapists will be performing post-race massages after the Missoula Marathon and we will have our IASTM tools available if you want to try this technique out.

Look for the MASSAGE signs at Caras Park from 8:00 am to 1:00 pm. All massages are 15 minutes for $20. Sign up when you register for the race or at our booth upon completing your run.​For more information, visit our clinic web page on this topic by clicking here.

Special thanks to star physical therapist Antara Quiñones for providing this write up on a recent article from the Journal of Hand Surgery.

**************​Mallet finger typically occurs with “jamming your finger”, like hitting a basketball with a straight finger, forcing it to bend when not expected. If the tendon that attaches near the base of your fingernail is unable to withstand this sudden force, it “avulses” or rips out of the bone creating a droopy fingertip. Unless this tendon is reattached somehow, you will never be able to straighten the tip of your finger again. Typically, this does not interfere with your ability to do things.

People seek treatment because they are more concerned about how their finger looks. A small percentage of mallet finger injuries can progress to a “swan neck deformity” where the tip of your finger is stuck pointing down and the middle knuckle is hyperextended in the opposite direction. This does interfere with finger function and treatment is typically necessary.

Treatment options for mallet finger vary depending on the length of time after injury that the droopy finger shows up (its not always immediate). Treatment is deemed successful if there is little or no “extensor tendon lag,” meaning you are able to straighten your finger fully.

The most conservative treatment option is long term splinting. This involves wearing a specially made finger brace that holds your finger in a neutral position in hopes that the tendon will reattach via scar tissue. This can be anywhere from 6 to 14 weeks. Most patients see acceptable success with splinting alone–their finger tip may be not quite straight but less noticeably bent–and do not seek further treatment.

Surgery is the next step if splinting does not work. However, recent review of the literature suggests that despite many different applications of surgical procedures, results are relatively no better than splinting alone.

Authors of this literature review concluded that splinting should be the primary treatment for a mallet finger, especially if it has been longer than 4 weeks since the injury. Their reasoning being that splinting is just as effective as surgery, a mallet finger typically does not interfere with day to day life, and is corrected typically for aesthetic purposes only.

Special thanks to star physical therapist Antara Quiñones for providing this write up on a recent article from the American Journal of Sports Medicine.

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Physicians are changing how they manage meniscal tears, according to a recent study that reviewed treatment methods over a 7 year period. Often when new evidence shows a better way to treat a problem it takes years for surgeons to alter their practice methods. This study concluded that surgeons have changed their treatment to reflect the most up to date practice. The authors attribute the change in treatment to new evidence and changes in physician education regarding effective treatment. This is good news for the prevention of knee arthritis.

The meniscus is a c-shaped piece of cartilage that is found on both sides of the knee joint sandwiched between the ends of your bones. It serves as a barrier between the leg bones, helps to redistribute twisting forces and decreases the wear and tear on the underlying cartilage covering the end of the bones.​The meniscus may be torn either by degeneration or by acute trauma. Sometimes from a blow to the knee both the meniscus and the anterior cruciate ligament (ACL) tear. A tear typically causes knee locking and catching, swelling, and pain. In the past, the standard treatment for a torn meniscus was removal, or meniscectomy. However, because recent studies have shown 60% of menisectomies result in osteoarthritis (or the wearing away of the cartilage covering the end of the bones), physician education has changed to emphasize preserving the meniscus. The attempt to preserve the meniscus is called a meniscus repair and involves suturing the structure back together as best possible.

Review of over 2 billion patient records from 2005-2011 showed an increase of 11.4% in the number of meniscal repairs, with young males and patients under 25 years old having the greatest increase in meniscal repair surgeries. Additionally, there was a 48.3% increase in ACL reconstruction in conjunction with meniscus repairs. This data suggests that physicians are changing their method of treatment of meniscus tears to reflect their training and are repairing meniscus when able instead of simply removing the tissue.